Dr. Anderson Spickard, Jr. / The Craving Brain: Science, Spirituality and the Road to Recovery (Excerpt)
My patient was slipping in and out of a coma,
near death from a severe inflammation of her liver. Francie’s tests for viral hepatitis had come back negative, and I explained to her family that we did not know why she was in liver failure.
“My sister is a recovering alcoholic who had been sober for twenty-seven years,” her sister said. “Four weeks ago, she took a drink to celebrate her wedding, and now she’s drinking a couple of bottles of gin a day.”
Francie survived and, after treatment for her addiction, remained sober the rest of her life. Others, like the brilliant actor Philip Seymour Hoffman, have not been so lucky. Hoffman had been drug-free for twenty-three years when he accepted a drink in 2012 at a post-production party for The Master, a film for which he received an Oscar nomination. Less than two years later, he was dead from a mix of drugs that included cocaine, prescription pills, and heroin.
The vulnerability of recovering addicts
The speed with which both Hoffman and my patient fell off the wagon after decades of sobriety illustrates the greatest challenge facing individuals in recovery—staying sober in the face of what both clinical experience and a growing body of research suggests is a lifelong risk of relapse.
The ongoing vulnerability of recovering addicts is an apparent consequence of the long-term damage to the brain caused by heavy drinking and drug use. As we have seen, this damage affects not just the reward system (with its critical task of regulating dopamine and other neurotransmitters) but also the cells and circuits that underlie our emotions, memories, reflections, and decision-making ability. The result is a neurobiological addiction network that at least one study suggests may continue to develop even during long periods of sobriety.
The Brain's Addiction Network
Whether lying dormant or expanding, the brain’s addiction network appears to be permanently sensitive to reactivation by a host of internal and external signals. Unfortunately, these cues include not just drinking or using but a long list of experiences, behaviors, and thoughts, most of which are intrinsic to being human and cannot be avoided. Memory distortions, including the euphoric recall of drinking and other drug use, may last a lifetime.
Some of the most dangerous cues may even lie outside of conscious awareness. At the University of Pennsylvania, researchers showed cocaine addicts photos of drug-related items like crack pipes and rocks of cocaine for just thirty-three milliseconds. Although this was too fast for the subjects to even know that they had seen a picture, MRIs showed their brains lighting up in the very areas thought to be related to craving and drug-seeking behavior.
The combination of a hypersensitive brain with the unavoidability of triggers helps explain why so many individuals in recovery return to problem drinking or other drug use. Although multiple studies confirm that drug monitoring programs—with swift, certain, and meaningful consequences—dramatically reduce and in some cases virtually eliminate relapse, such programs are expensive and rare. The vast majority of recovering individuals must use other methods for finding the internal and external motivation they need to stay sober.
Fortunately, research-based guidelines and practices are available for sustaining recovery over a lifetime. They are free and universally available, and they enable addicted individuals to generate the new memories and learned behaviors that, in turn, create something of a recovery network in the brain. Whether these cells and pathways replace, override, or circumvent the addiction network remains to be discovered. Whatever the case, the recovering brain becomes capable of generating thoughts and behaviors to support, rather than sabotage, long- term sobriety.
Dr. Spickard is Emeritus Professor of Medicine and Psychiatry at Vanderbilt University Medical Center. He has been active in the practice and teaching of internal medicine for over 45 years. He was the founding medical director of the Vanderbilt Institute for Treatment of Addiction for years and the Past Medical Director of The Center for Professional Health at Vanderbilt.